With the wide availability of wearable fitness trackers, people have been increasingly measuring the number of steps they take per day, striving to obtain those 10,000 steps. But what is the significance of 10,000 steps? And is counting steps really a good measure of physical activity? I recently attended the International Society for Behavioral Nutrition and Physical Activity (ISBNPA) Annual Meeting in beautiful Victoria, British Columbia where I was fortunate to gain more insight into the step counting phenomenon.

Catrine Tudor-Locke, a professor at UMass Amherst, is one of the pioneers of using pedometers and accelerometers to measure physical activity. Her research has informed many of the wearables that are commonly used today. Dr. Tudor-Locke gave a fascinating talk on step-counting, recounting the following points:

Step counting has been around for a while! The Romans measured the distances their legionaries traveled based on counting steps. In fact, the word “mile” is derived from the Latin “mille passus,” or one thousand paces.

The average healthy young adult (20-50 years of age) takes about 7,000-13,000 steps a day; adults under 65 years of age take 5,400-18,000 steps a day (although the higher end of that, 18,000, was from one study of Amish men, who probably walk more than the average American).

Rather than addressing step counting, physical activity guidelines for adults focus on time spent in moderate-to-vigorous physical activity (also known as MVPA). The American College of Sports Medicine and the American Heart Association suggest that healthy adults need at least 30 minutes of moderate-intensity aerobic physical activity per day on five days a week; similarly, the US Department of Health and Human Services calls for “at least 150 minutes (2 hours and 30 minutes) a week of moderate-intensity.”

But what about all these step counts? Dr. Tudor-Locke’s research suggests that despite some inter-individual variation, 100 steps/minute is equivalent to at least moderate intensity walking. So 3,000 steps in 30 minutes would meet the guideline of 30 minutes of moderate-vigorous physical activity per day. Adding this to the regular steps from everyday activity, on average one would need to obtain 8,000 to 11,000 steps per day to meet physical activity guidelines.

And in fact, studies demonstrate that people who obtain 10,000 steps per day do meet the guideline of 150 minutes of MVPA per week. An Australian study using pedometers showed that adults who self-reported accumulating at least 150 minutes of MVPA in a week averaged 9,547 steps/day. In Dr. Tudor-Locke’s work in the US, people reporting 150 minutes/week of MVPA were getting in about 7,000 steps/day. So, achieving 7,000 steps appears to be enough to meet guideline recommendations.

Can you get better health from more steps? To date, many studies have shown that a higher number of steps per day is associated with positive health outcomes, including lower prevalence of depression, lower BMI, and smaller waist circumference.

But maybe we are going about this all wrong. Isn’t there a health benefit if we take 9,999 steps in a day? And isn’t 12,000 steps better than 10,000? And for folks who don’t get a lot of physical activity, isn’t 2,000 steps better than 0? Tudor-Locke discourages the single-minded pursuit of threshold values: “From a public health practice point of view it is both rational and appealing to focus on motivating behavior change in the larger portions of the population with low to very low physical activity levels, rather than to focus solely on tailoring messages that may very well only appeal to subsamples that are already comparatively active.”

Or, more simply said, no matter if you’re getting 10 or 10,000 per day, every step counts!

Silver Diner, a full-service restaurant chain in the Washington, DC, metro area, did just that. They expanded the percentage of “healthy” kid’s entrees from 22% to 59% of all offerings. They defined “healthy” according to criteria established by Kids Live Well, an industry-led voluntary initiative to encourage restaurants to offer more options low in calories, fat, sugar, and salt. They also dropped fountain drinks as an option on the kid’s menu, leaving only 100% juice or milk available. Strawberries, mixed vegetables or salad replaced fries and home fries as the default side item options. Kids could still request fountain drinks or fries as a substitute, at no additional charge, but they had to ask for those items. What happened? Researchers from Tufts University and ChildObesity180 found that the percentage of “healthy” kid’s entrees sold rose from a meager 3% before the changes to 46% after. While 57% of kids chose fries before the menu changes, 22% did after. Those choosing strawberries rose from 29% to 63%, while the proportion of kids choosing salads and mixed vegetables rose just over 1%. Consumption of fountain drinks dropped 5%, accompanied by slight increases in milk and 100% juice. A follow-up study with data for 2 years after the default changes demonstrated persistent improvements in the diet quality of meals purchased. Disappointingly, the overall average calories from meals didn’t change, but meals with the new defaults for their sides contained about 60 fewer calories than before the menu changes. Another similar study conducted in a Mexican fast-food restaurant in the Seattle area found complementary results. This chain changed the default side on their kid’s menu from a high-calorie fried potato dish (“Mexi-Fries”) to a menu of options that included 2 lower calorie items (beans or rice); they also added applesauce as a dessert option instead of only offering a default high-calorie desert (a fried and sugar-coated tortilla strip). Researchers followed sales immediately after the menu changed and then later, when the healthy changes were highlighted and promoted by the restaurant. Sales of the high-calorie desert decreased right after applesauce was included as an option, but the Mexi-Fries held fast until the alternate and lower-calorie sides were promoted as an option. The changes weren’t dramatic (around 1% decline in sales for the higher-calorie items per month), but it was slow and steady over the 23-month study. Calorie labeling might work this way as well. After King County (Seattle), Washington, implemented a local law that required chain restaurants to label calories on their menus, calories in entrees on menus before and after the labeling implementation fell an average of 73 calories for full-service restaurants and 19 calories for fast-food restaurants. This means that restaurants likely reformulated these products to be lower-calorie (or made them smaller into portions) after the law went into effect. This is not to say that some people won’t respond to dietary information in the form of labels or any other health education. However, if restaurants make it easier for people, they may decrease calories without even thinking about it. Customers can still choose the higher-calorie item if they want, but they have to make an active choice to do so. Here’s hoping that restaurants do more of this, spending their time and energy reformulating items so that they retain their taste but at slightly lower calories. By default.

In the August 2017 issue of Pediatrics, several colleagues and I reported that mothers who consumed more sugary beverages – including sugary soda and fruit drinks – in mid-pregnancy had children with higher amounts of body fat in mid-childhood, even when we considered the children’s own intake of sugary beverages. We also examined the effect of drinking water and 100% fruit juice during the same time period, and found no associations between these drinks and children’s later body fat. We hypothesized that the second trimester of pregnancy may be a sensitive period with regards to children’s body fat deposits, and that avoiding high intake of sugary beverages during pregnancy may reduce the risk of childhood overweight and obesity. Click on the Read More button for the Pediatrics’ press release…

STUDY: CONSUMPTION OF SUGARY DRINKS IN THE 2ND TRIMESTER LINKED TO KIDS’ WEIGHT IN MID-CHILDHOOD

School-age children whose mothers consumed more sugary beverages in mid-pregnancy had higher amounts of body fat than those whose mothers drank fewer sweetened beverages, according to a study published in the August 2017 Pediatrics. The study, “Beverage Intake During Pregnancy and Childhood Adiposity,” to be published online July 10, looked at 1,078 mother-child pairs in a pre-birth cohort study in Massachusetts. Researchers measured the mothers’ intake of sugary and non-sugary beverages during their first and second trimesters of pregnancy between 1999 and 2002. They found an association between mothers who drank more sugary beverages during their second trimester and their children’s excess weight by mid-childhood, at a median age of 7.7 years. Among 8-year-old boys and girls of average height who consumed at least a half a serving a week of sugary beverages, their weights were approximately 1 kg higher if their mothers had consumed at least two servings a day of sugary beverages while pregnant. Maternal intake of the sugary beverages – rather than the child’s diet – was more strongly related to the child’s susceptibility to gaining excess weight. Avoiding high intake of sugary beverages during pregnancy could be one of several ways to prevent childhood obesity.This research paper has gained wide-spread media interest and was covered nationwide including but not limited to Reuters, The Boston Globe, The Philadelphia Inquirer, and Science News.

Most parents, nutritionists and educators will agree that it’s not easy to get kids to eat fruits and vegetables, especially in school. In this earlier blog post, Dr. Jenn Woo explained the importance and effects of improved school meal standards, which have since been changed again by the Trump administration. It is well-established that providing nutritious, affordable school meals is important in controlling childhood obesity and there is broad support for this initiative from physicians, and former First Lady Michelle’s Obama’s Let’s Move campaign. However, the best way to implement improved standards is controversial. There’s also the important question, raised in Dr. Woo’s post, of whether kids will actually eat these healthier meals and learn to appreciate fresh, nutritious food.

Rather than a “top-down” approach which forces healthy foods upon resistant children, it might be more effective to motivate kids to want to eat healthier foods. One approach is to implement programs that help kids feel more connected to the food cycle and that encourage awareness of what they are eating and how it affects their bodies and health. Local programs such as CitySprouts and Groundwork Somerville’s Schoolyard Gardens aim to increase kids’ awareness of where food comes from and to get them personally involved in growing and preparing food. Instead of being handed a nondescript, overcooked vegetable on a tray at lunch time, kids help to plant, maintain, and harvest gardens in their schools, while learning science, math, engineering, and nutrition along the way. School gardens also provide an opportunity for kids to spend time outside, be physically active during the school day, build social skills by working together, and establish a connection to nature and their community. This all sounds great, but is it actually effective in improving nutrition and general health among school children? A review of 13 studies examining the impact of school garden programs on dietary behaviors of children in grades K-8 found evidence for increased intake of and preference for vegetables following implementation of the garden programs. The garden programs also resulted in increased willingness to taste fruits and/or vegetables and improved identification of the different fruits and vegetables. Finally, children felt more confident in their ability to cook and prepare fruits and vegetables after participating in a school garden program. Another study investigated the impact of a school garden intervention in low-income elementary schools in New York on physical activity. The investigators found that children attending schools receiving the garden intervention had a larger decrease in sedentary activity and a greater increase in moderate-to-vigorous physical activity during the follow-up period compared to children attending a control school. The kids in the intervention schools were also more active during lessons based outdoors in a garden vs. indoors in a classroom. My own sample size of 1 has also revealed great success with this approach. Last summer, my son had little interest in eating cherry tomatoes that appeared on his plate from a store-bought package. However, we also grew our own tomato plants, and once the tomatoes appeared he ran excitedly to the back door every morning to check for tomatoes that had turned from green to red or yellow and begged to pick and eat them! Given that schools have had limited success in actually getting kids to eat healthier foods, a major factor cited by critics of the improved school nutrition standards, it might be time for wider implementation of approaches that focus on getting kids more personally invested in food and nutrition. School gardens are one such approach that has already shown success in many different settings and has added benefits to children’s health.

Despite a good run of over 50 years in the business, McDonald’s decided late in 2016 that the services of its friendly, funny clown, Ronald McDonald, were no longer required. The clown, it seems, had become a threat to public health. Why? Not because he was pushing trans fats on toddlers, selling sodas to six-year-olds, and hawking hamburgers to high-schoolers. Rather, this sudden call to action by McDonald’s execs was out of grave concern that Ronald might be.......scaring people (Gasp!!) After a series of creepy clown sightings across the United States last fall, it was felt that Ronald’s continued presence as a McDonald’s ambassador might be upsetting to children.

The irony of this decision, of course, is that good ol’ Ronnie has done far more damage to American children over the years by getting them hooked on unhealthful, calorie-dense foods and beverages than he has by conjuring up images of scary clowns from a bad horror flick. With his goofy charm and cadre of fuzzy buddies, Ronald has been a key part of the food industry’s drive to market junk directly to children, who, it turns out, are very susceptible to such tactics. This phenomenon is plainly evident if you spend 30 minutes watching cartoons with your child on a Saturday morning, then take him/her on a tour of the grocery store. In fact, a large body of research suggests a clear link between exposure to food advertising and the preferences and eating behaviors of children. Public health advocates have been trying for well over a decade to implement policies that limit the ability of companies to market potentially harmful products directly to young children. This has taken the form of legislation restricting food advertising to kids under 16 in the UK, as well as attempts in a number of countries (including the US) to engage food industry leaders in voluntary pledges to change the way they market their products. Whether or not these pledges have translated into meaningful changes in marketing by food industry players is an area of concern. A 2016 World Health Organization update on food marketing restrictions concluded that, despite existing resources for technical and policy guidance from the United Nations, there had not yet been a Member State that “implemented comprehensive legislation or enforced mandatory regulations to prohibit the marketing of unhealthy food and beverage products to young people”. Furthermore, the update indicated that the food industry, despite pledges to the contrary, had made little progress on their own in restricting marketing of unhealthful products to young children. This brings us back to Ronald the clown, now out of a job, but for the wrong reason. If a direct appeal to companies on the ethics of marketing junk to children has been unsuccessful, then perhaps Ronald’s fate can teach us a lesson. Perhaps we should instead be partnering with the entertainment industry to pump out more films about creepy clowns, or better yet – deadly diabetes, horrific heart disease, and the other true terrors that keep most of us medical types up at night.

Evolution says that I shouldn’t eat too much ice cream. An article in Maclean’s, a Canadian weekly current affairs magazine, made the argument that eating similar foods to what your grandparents ate – or better yet, what your great-great-great grandparents ate – is the key to a long and healthy life. The idea behind this notion is that foods that are healthiest for you may be tied to your specific cultural and genetic history. This concept really hit home a few nights ago when I watched my husband, who is of German descent and comes from a family of dairy farmers, chase a bowl of ice cream with a glass of milk without a trace of indigestion. Me? On a good day, I can only eat a small amount of baked or fermented dairy unless I plan to spend the next few hours on the porcelain throne. This is likely a remnant of the fact that my ancestors in Taiwan did not practice dairy husbandry and as a consequence, dairy has not historically been a part of the Taiwanese diet, rendering many Asians like myself lactose-intolerant. Therefore, while a dairy-rich diet may be perfectly fine for my husband, I am better off consuming smaller amounts of this food group. Pass on the juice cleanse and the coconut oil! The author of the Maclean’s article also discussed how many popular diets considered to be “healthy” may actually be detrimental. For example, while fruits and vegetables are undoubtably beneficial to our health, the ever-popular juice cleanses expose us to much higher levels of fructose and uric acid than our ancestors were ever exposed to and can result in insulin resistance, high blood pressure, and gout. Likewise, the recent emphasis on eating raw foods (think: Paleo diet) may lead to increased consumption of toxins in uncooked vegetables (e.g., cyanide in lima beans and phytates in peas and tomatoes). Excreting and neutralizing these toxins may not only deplete our bodies of important minerals, but can also lead to indigestion. In the long-term, following mainstream diet fads – even those that have received positive support from the research community, like the Mediterranean diet (discussed in Gary Paul Nabhan’s book Food, Genes, and Culture: Eating Right for Your Origins) – can result in suboptimal health outcomes. So, what is the take-home message? With all the different recommendations on how to eat optimally for good health, it’s a tough world to navigate for the average consumer. As someone with a background in nutrition, epidemiology, and obesity, I would say that it’s a good idea to eat whole foods (particularly those that your grandmother would approve of), while limiting your consumption of processed foods with a long list of impossible-to-pronounce ingredients. And of course, moderation is key; if something is tasty, eat some (but not too much) of it!

A recent poll conducted by Truven Health Analytics and National Public Radio got press coverage for its finding that the majority of surveyed Americans characterized their eating habits as “good, very good or excellent”. This was surprising given that more objective measures of our diets are generally pretty poor - the average Healthy Eating Index (HEI) score for Americans 2 years and older is 59, out of a possible 100 points! That’s not great, and certainly not consistent with the way these survey respondents viewed their eating habits. What did not make the headlines, but is perhaps of greater interest to the nutrition science community, were poll responses that suggest that many Americans completely missed some of the major changes in the 2015 Dietary Guidelines for Americans (DGA), despite the media hubbub that surrounded their publication.

The poll, conducted by phone or on the web for 3,007 participants between May 1-14, 2016 included several questions on dietary fat and foods high in cholesterol. The majority of those surveyed (74.4%) were unaware of the removal of limits on foods containing cholesterol from the updated DGA. Among those who were aware, over half (64.2%) said they had not changed their intake of “high cholesterol” foods based on the new DGA, and 14% had actually decreased their intake. When respondents were asked if they were generally confused about the amount and type of fats that make up a healthy diet, most indicated “no” (64.7%), although levels of confusion were highest in those younger than 35 years old, of whom 44.9% were confused. The results of this survey are certainly subject to limitations of its methodology, which is somewhat hard to assess with the available information on the surveyor’s website. For example, the wording of the survey questions was less than ideal in many cases and could have led to different interpretations by respondents. Additionally, there was no information provided on sampling strategy or whether they felt they got a group that was representative of the American public. Available co-variates were limited, probably due to brevity of the poll, and did not include any health-related data points such as weight status or chronic illnesses. The survey website highlights “statistically significant” responses in bold but does not specify which statistical test was used, the threshold for statistical significance, or what groups were being compared. Despite the methodological limitations of this poll – which, in fairness, did not aim to be a peer-reviewed research study – it is interesting that most surveyed Americans were not remotely familiar with one of the most widely publicized aspects of the 2015 DGA. This may be reflective of the public’s fatigue with ever-changing recommendations of nutrition experts. Perhaps people are so tired of overhauling their diets every few years that they have just stopped listening? Or perhaps the guidelines were so vast that some of these changes simply didn’t register? Either way, it’s possible that the majority of Americans now think that they are eating healthy diets, report that they are not confused about topics such as dietary fat, and yet have apparently tuned out any updates from the nutrition science community. Moving forward, it will be important for experts to consider how to re-engage the public with this topic, streamline their messaging, and provide a clear justification for any changes in dietary recommendations (and this cannot just be “we got it wrong before”). Otherwise, all that Americans will hear when we speak is: “Wah wah wah, wah wah wah…..”

I recently bought a hand-sewn bridesmaids dress online, created to my specifications to fit my body. Yet, like many aspects of a wedding, reality did not meet expectations. In fact, it ended with my bust, waist and hip measurements posted online for the world to see….but that’s a different post for a very different blog. I was sent three sets of instructions for obtaining the same body measurements. One told me to measure my waist circumference at my belly button, another identified my waist as the smallest portion of my torso, while the third indicated that waist measurements should be taken at the top of my hipbone. I don’t know about you, but my belly button is not located on my hipbones, nor is that the smallest part of my torso. Considering that the company was providing very different instructions for measuring the same thing, I should NOT have been surprised when my dress came back 6 inches too short and two sizes too big. Two hundred dollars in alterations (and a visit to the Better Business Bureau) later, I was left wondering, if differences in measurement instructions can affect my apparel this dramatically, what is it doing to the quality of our research?

In public health research, we often critique the methods; less often do we question the actual data. Yet data quality can impact every aspect of analysis. Much of the data used in studies of nutrition or weight is susceptible to human error. Studies commonly rely on at least some form of manual anthropometry – literally, measurements of the body – in their data collection, even if it is a relatively simple height measurement. Most inaccuracies in anthropometric data collection are a result of observer error. A Project Viva study led by Sheryl Rifas-Shiman showed that clinical measurements of toddler length were systematically overestimated by an average of 1.3 cm. While this error may seem minimal, it could result in extensive misclassification of weight status, and lead researchers to inappropriate conclusions about their data. In research, especially longitudinal research, where individuals are assessed at several points in time, it is essential that protocols are standardized so that a participant’s waist isn’t measured at her belly button one day and at her bra-line the next. At Project Viva, a longitudinal pre-birth cohort study, we have collected anthropometry measurements from mothers and children for over 17 years. In order to maintain high quality data collection in the face of a changing study team, we have developed a stringent, yet easy-to-follow protocol for obtaining anthropometry measurements. With this protocol and attention to quality control procedures, our research team has, and will continue to, produced high-quality, reproducible results. Most recently, with the help of an online video journal, we have published our protocol, quality control, and training procedures for the purposes of improved data collection and pooling of results. We have put in the ground work, so other studies don’t have to. This post is a call for everyone doing similar research to use standardized methods that can withstand the test of time. Or they could just use our procedures, so that we are all on the same page about where our waists are. Please don’t let your research turn out as imperfect as my bridesmaids dress.

A friend recently told me that she gained 30 pounds during the first trimester of her pregnancy. Because I work in obesity research, she asked me if that sounded like too much. I suggested that she talk to her doctor, and she said “Well, if it was a problem, wouldn’t my doctor bring it up with me?”

For almost everyone, weight is a touchy subject. Despite written guidelines and research on how clinicians can approach – and not offend – patients when discussing their weight, studies have long shown that both patients and providers are hesitant to bring up the topic during clinic visits. Add the complicating factor of pregnancy, and it may not come as a surprise that this reluctance extends to discussing weight gain with pregnant patients In an earlier blog post, Emily Oken illustrated the importance of appropriate weight gain during pregnancy, describing how gaining too much weight during a pregnancy can have negative health consequences for both the mother and the child. But despite this evidence, some women, like my friend, expect the doctor to initiate conversation related to weight gain limits and concerns. Doctors are hesitant to bring up the topic as well. One of the research projects in our group aims to address this issue. Our investigators are recruiting both pregnant women and their providers to participate in a two-part trial aimed at facilitating these tough discussions. In the first part of the study, researchers are providing physicians with training and tools so they feel more comfortable addressing excess weight gain during pregnancy. Physicians are coached on strategies for addressing weight issues with patients, as well as new tools in the electronic health record that display growth trajectories during pregnancy. These trajectories will give physicians a quick way to determine whether patients are on track to gain a healthy amount of weight during pregnancy. Together, these tools and strategies are intended to facilitate delicate discussions of excess weight gain during pregnancy. In the second part of the study, pregnant women will be paired with a mobile app and a health coach. The coach will work directly with the patient, discussing the woman’s weight goals, strategies to achieve those goals, and also noting whether her physician discussed weight gain with the patient. Our goal is to empower both patients and providers to have these difficult discussions, so that no one is left wondering after an appointment, “is that something I should have brought up?”

If you ever dare to venture into the comments section of any article about weight, weight loss, obesity, exercise or health, eventually you’ll find someone who says some version of the following: “All people have to do is eat less and exercise more, and they’ll lose weight.” In a broad sense, this is true; calories are energy, and our bodies use that energy to fuel our basic bodily functions, like circulation, respiration, digestion, and physical activity. Excess calories are stored by the body as fat. Yet it also grossly oversimplifies the complexity of our metabolisms.

A recent article in the New York Times had the provocative title “Skinny and 119 Pounds, but With the Health Hallmarks of Obesity.” It described the case of Claire Walker Johnson, a woman who could and did eat whatever she wanted without gaining weight. Yet despite having a Body Mass Index of 18.6 kg/m2, considered borderline underweight, Ms. Johnson had many of the health conditions commonly associated with obesity, including fatty liver disease; ovarian cysts; high blood pressure, cholesterol and triglycerides; and Type 2 diabetes. Her baffled doctor searched for years for the cause of her contradictory health conditions and eventually learned of a rare genetic condition called lipodystrophy. Patients with lipodystrophy have abnormally low levels of fatty tissue in their bodies. Ms. Johnson’s lack of fatty tissue triggered a vicious metabolic cycle; with too little stored body fat, her brain received too little of a hormone called leptin, which is produced by fat cells and, among other things, regulates satiety, or fullness. Her brain registered her low levels of leptin and body fat, concluded that she was starving, and commanded her to eat. And yet she was unable to store the excess calories she consumed as normal fatty tissue. Instead, the fat accumulated in her liver and remained circulating in her blood. When she participated in a clinical trial of a synthetic version of leptin, her liver recovered and her blood glucose and cholesterol levels dropped to normal levels. As mentioned, metabolism is complex, and Ms. Johnson is the perfect case of a rare condition that leads to very atypical patterns. Another recent, high-profile study highlighted the metabolic consequences of major weight loss among another rarified group – participants on the reality television show The Biggest Loser. The show challenges contestants to see who can lose the most weight. The winner receives a huge cash prize. Over the years of this show, many participants have demonstrated an enormous amount of weight loss. Danny Cahill, the winner of season 8, lost 239 pounds over 7 months, or more than half of his baseline body weight of 430 pounds. Yet when NIH researchers conducted a study of Cahill and some of his fellow competitors 6 years later, they found that most, including Cahill, had regained at least some of the weight they had lost. They also found that contestants’ resting metabolic rates (RMRs), the number of calories their bodies needed for basic biological functions and to maintain their weight, were unexpectedly low. To a degree, RMR reflects weight. People with overweight and obesity tend to require more daily calories than those who weigh less, and the RMR declines with weight loss. What makes this such a challenge is that the decline in RMR may be disproportionate to the weight lost. In other words, a person who weighed 200 pounds and lost 50 typically has a lower resting metabolic rate than someone who has maintained a steady weight of 150 pounds. In Danny Cahill’s case, they found that he required 800 fewer calories per day than expected at his current weight of 295 pounds. While the precise mechanism of this metabolic slowdown is unclear, the same researchers found an association between low levels of leptin and lower RMR in an earlier study, also involving Biggest Loser contestants. This makes maintaining weight loss very, very difficult. My point isn’t that it’s impossible for anyone to lose weight, or that we’re simply at the mercy of our hormones and metabolisms. One of my favorite quotations, however, is “be kind, for everyone you meet is fighting a hard battle.” Weight loss is ultimately far more complicated than “eat less and exercise more,” involving many different factors, and the stranger on the street – or in the internet comments section – may be working harder than you realize to gain, maintain, or lose weight.